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HomeMy WebLinkAbout0035 PLEASANT STREET - Health 35.Plea'sant St. Hyannis rA- 327 123 `Capt. Al ' o I a N Massachusetts Depart zn n ' onmental Protection 100275089 BWP AQ 04 ANF-001) A _ W Asbestos Notifica 'on Form C sbestos Project# / r 'Project Revision Project Cancellation F.. . r INN A.::Asbestos Abatement Description _r. 1.Facility.Location: � e DOMINIC ALESSANbRA, 35 PLEASANT ST, Instructions 1.All a.Name of Facility b.Street Address fJ? sections of this form gARNSTABt_E _ must be completed in MA 02601 5082807290 order to comply with c.City/Town d.State e.Zip Code f.Telephone MassDEP notification SAME - OWNER requirements of 310 CMR 7.15 and g•Facility Contact Person Name In.Facility Contact'Person Title Department of Labor Worksite Location:_ _ RESIDENCE Standards(DLS) otiScaGon i.Bu!ding\am,;,Wing,Flc6r,Rocm,etc. requirements of 453 2.. Is the facility.occupied? l ;a.Yes rb.No CMR 6.12 3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility,or owner.-occupied residential property of four units or less)? a.Yes 17 b. No MassDEP Use Only z T 4.Blanket Permit Project Approval,if applicable: Date Received •. Approval ID# .:_.--..._ .__... 5.Noti-Traditional A`sbcstos Abatement Wort:Practice Approval, 2.Submit Original if appl cable: t° .`' Approval ID# Foim To: Commonwealth of Massachusetts 6. Asbest9s;CQntractor }. P.O.Box 4062 Boston,MA 02211 ASBESTOS MAN REMOVAL. 929 STATE ROAD _. m- - -• •-_- -�•-- -~ ` b.Address PLYM0UTH MA 02360 5082245500 c.City/Town • , d.State e.Zip Code f.Telephone AC000342 h.Contract Type: r 1.Written W 2.Verbal g.DLS License# 7. ELMER E,PINEDA AS001291 a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification# 8 N/A a.Name of Project Monitor b.DLS Certification# 9. N/A a.Name of Asbestos Analytical Lab b.DLS Certification# 10. 11/2/2017 1 1/2/2017 a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY) 3PM-9PM 3PM 9PM c.Work Hours-Monday Through Friday d.Work Flours-Saturday&Sunday 11.What type of project is,this? j a.Demolition j ; b.Renovation I`.; c.Repair` f- d. Other-Please Specify: Revised: 11/13/2013 `� Page 1 of 4 Massachusetts Department of Environmental Protection —--- -- BWP AQ 04 (ANF-001) 100275089 Asbestos Project# Asbestos Notification Form l W. Project Revision l` Project Cancellation A.Asbestos Abatement Description: (cont.) 12.Abatement procedures(check all that apply): a.Glove Bag " b.Encapsulation € c.Enclosure r d.Disposal Only [ . e.Cleanup r7 f.Full Containment r' g.Other-Please Specify: 13. Job is being conducted: �" a. Indoors l`"'; b. Outdoors 14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or encapsulated: 27 1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.) b.Boiler,Breaching,Duct, c.Transite Pipe Tank Surface Coatings 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. d.Pipe Insulation 27 e.Transite Shingles 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. f. Spray-On Fireproofing g.Transite Panels 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. h.Cloths, Woven Fabrics i.Other-Please Specify: 1.Lin.Ft. 2.Sq.Ft. j. Insulating Cement 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. 15.Describe the decontamination system(s)to be used: REMOVE ASBESTOS USING GLOVEBAGS 16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): WET DOWN ASBESTOS AND DOUBLE BAG USING 6 MIL MARKED AND LABELED BAGS 17. For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency: a.Name of MassDEP Official b.Title of MassDEP Official c.Date of Authorization(MM/DD/YYYY) d.Waiver# e.Name of DLS Official f.Title of DLS Official g.Date of Authorization(MM/DD/YYYY) h.Waiver# 18. Do prevailing wage rates as per M.G.L.c. 149, §26,27 or 27A—F apply to this a.Yes l✓ b.No project? Revised: 11/13/2013 Page 2 of 4 i i 4 f Massachusetts Department of Environmental Protection ---- 275089� BWP AQ 04 (ANF-001) E 100-- I Asbestos Project# . Asbestos Notification Form Project Revision f7. Project Cancellation B. Facility Description 1.Current or prior use of facility: RESIDENCE 2. Is the facility owner-occupied residential with 4 units or less? 1%�- a.Yes r7. b. No 3 DOMINIC ALESSANDRO 35 PLEASANT ST. a.Facility Owner Name b.Address BARNSTABLE MA 02601 5082807290 c.City/Town d.State e.Zip Code f.Telephone 4.N/A N/A a.Name of Facility Owner's On-Site Manager b.Address N/A MA 02601 5082807290 c.City/Town d.State e.Zip Code f.Telephone 5 N/A N/A a.Name of General Contractor b.Address N/A MA 02601 5082807290 c.City/Town d.State e.Zip Code f.Telephone N/A g.Contractor's Worker's Compensation Insurer 99999999999999999999999999999999 9/9/9999 h.Policy# i.Expiration Date(MM/DDNYYY) 6. What is the size of this facility? 2000 2 a.Square Feet b.#of Floors C. Asbestos Transportation & Disposal 1.Transporter of asbestos-containing waste material from site of generation: a. Directly to Landfill or PW b.To Temporary Storage Location/Transfer Station ASBESTOS MAN REMOVAL CO 929.STATE RD Note:Temporary c.Name of Transporter d.Address storage of Asbestos PLYMOUTH MA 02360 5082245500 containing waste e.City/Town material is only f.State g.Zip Code h.Telephone allowed at the place of business of a licensed Aso sa DLS 2. If a temporary storage location/transfer station is used,list name of transporter of asbestos containing contractor or a transfer Waste material from temporary storage location/transfer station to final disposal site: station that is permitted by JOB ROLLOFF POB 609 MassDEP and a.Name of Transporter b.Address operated in compliance with Solid HAMPSTEAp N 1 03841 6173871495 Waste Regulations City/Town 310 CMR 19.000 c. d.State e.Zip Code f.Telephone Revised: 11/13/2013 Page 3 of 4 Massachusetts Department of Environmental Protection 100275089 Ll BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form f` Project Revision f" Project Cancellation C.Asbestos Transportation&Disposal: (cont.) 3.Name and address of temporary storage location/transfer station for the asbestos containing waste material: ASBESTOS MAN REMOVAL CO 1428 BEDFORD ST a.Temporary Storage Location Name b.Address ABINGTON MA 02351 5082245500 c.City/Town d.State e.Zip Code f.Telephone 4. Name and location of final disposal site(asbestos landfill): TURNKEY LANDFILL WASTE MANAGEMENT a.Final Disposal Site Name b"Final Disposal Site Owner Name 90 ROCHESTER NECK RD c.Address ROCHESTER NH 03839 6033390039 d.City/Town e.State f.Zip Code g.Telephone D. Certification PAULILACQUA PAULILACQUA "I certify that I have personally 1.Name 2.Authorized Signature examined the foregoing and am PRESIDENT 10/20/2017 familiar with the information Note:Contractor must contained in this document and 3.Position/Title 4.Date(MM/DDNYYY)sign this form for DL 5082245500 AMR COS all attachments and that,based _ notification purposes on my inquiry of those 5.Telephone 6.Representing individuals immediately 929 STATE RD PLYMOUTH responsible for obtaining the 7.Address 8.CitylTown information,I believe that the MA 02360 information is true,accurate,and complete. I am aware that there 9•State 10.Zip Code are significant penalties for submitting false information, including possible fines and imprisonment. The undersigned hereby states that I have read the Commonwealth of Massachusetts regulations governing asbestos abatement (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department of Environmental Protection), and that I am aware that this permit application or notification shall not be deemed valid unless payment of the applicable fee is made." Revised: I I/13/2013 Page 4 of 4 !� a �� , ,,�� (mac y„� r EXAMINATION FORM NO : 2047 CERTIFICATION NO : 3366103 TO AMY HE ILMANN for successfully completing the standards set forth by the National Restaurant Association Educational Foundation for the ServSafe' Food Protection Manager Certification Examination, which is recognized by the Conference for Food Protection (CFP). I'msented 11,;the Alational Restatcrcrrz.tActociettic�n &tarccztiv-peal Foundation 2/26/2003 i DATE OF EXAMINATION 2/26/2008 DATE OF EXPIRATION ' Check with your local Health department for their specific requirements. 1 i MARY M, ADOLF: PRESIDENT. AND CHIEF OPERATING ,OFFICER; N AT I O N A C R E S TA U R A N T ASSOCIATION NatiOnaI Restaurant Association. EDUCATIONAL FOUNDATION' V National Restaurant Association Educational Poundation EDUCATIONAL FOUNDATION U 2002 Nalional Restaurant Association Educational Foundation www.nraef.or 02072005 v.021# g 1 TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION Date 5/90, 0 Owner ate' AVY-k.,n r1 Tenant Address 35 G)) k—Si— Address Complionce Remarks or Regulation# Yes No Recommendations 2. Kitchen Facilities.L) 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities �Pa 7. Lighting and Electrical Facilities 8. Ventilation -5ex—Q)Q,) Y-%, "9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural 10���. ©Q �,�.� Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal >/ 16. Sewage Disposal 17. Temporary Housing PART 11 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Person(s)Interviewed C'''r l�_ T) Inspector If Public Building such as Store or Hotel/Motel specify here f , TOWN OF BARNSTABLE DEC 1 Epp BOARD OF HEALTH ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION Date Owner t ��� 448,1 CA'-00el &6 Tenant Address . p� Address Complionce Remarks or Regulation# Yes No Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply I 1 —4-r 5. Hot Water Facilitiesea- i 6. Heating Facilities o 7. Lighting and Electrical Facilities 8. Ventilation �� to 1 9. Installation and Maintenance of Facilities V- ws W 10. Curtailment of Service o i 11. Space and Use 1911 Ad 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing OJA PART II cht, 07V r4zj�5 37. Plocarding of Condemned Dwelling; f•�� � Removal of Occupants; Demolition Person(s)Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here HOBBS&WARREN,INC. Z 213 502 63`3, US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for Interhational Mail See reverse [Sen Num P ice,State,&ZIP Coe Post $ Certified Fee Special Delivery Fee Restricted Delivery Fee LO Return Receipt Showing to Whom&Date Delivered n Return Receipt Showing to Whom, Q Date,&Addressee's Address O TOTAL Postage&Fees $ Co �. EPostmark or Date Q— J li / 7, U) d Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service m window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the m return address of the article,date,detach,and retain the receipt,and mail the article. C N 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article Q RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the O addressee,endorse RESTRICTED DELIVERY on the front of the article. c(. 5. Enter fees for the services requested in the appropriate spaces on the front of this E receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. �`8L 6. Save this receipt and present it if you make an inquiry. 102595-99-M-0079 a > I ��pFTHE rph�� Town of Barnstable * Regulatory Services * BA N rABLE. » y MASS. g Thomas F.Geiler,Director plfo3�a Public Health Division Thomas McKean,Director 367 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Mrs.Diane Dietz 35 Pleasant Street Hyannis,MA 02601 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00,STATE SANITARY CODE II, MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51 The property owned by you located at 35 Pleasant Street,Hyannis was inspected on September 19,2000 by Edward Barry, Health Inspector for the Town of Barnstable, because of a complaint. The following violations of 105 CMR 410.00,State Sanitary Code II,Minimum Standards of Fitness for Human Habitation were observed: • 410.500 Chipped paint in the hall way and on the stairs • 410.501 Missing pane in the bathroom window • 415.150 Toilet seat is missing • 415.602 Bathroom is not maintained in the sanitary condition • 410.550 F1ed� observed in the tenant's room • 410.481 Building has no 20 sq.inch sign showing owner's name,address, and telephone number. You are directed to correct 410.550 violation within twenty-four(24)hours of receipt of this notice hiring a licensed exterminAtor to remove infestation.. You are also directed to correct the remaining above listed violations within ten(10)days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7)days after the date order is received. However,these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than$500. Each separate day's failure to comply with an order shall.constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean Director of Public Health J The Town of Barnstable ° Health Department i out i 367 Main Strect, Hyannis, MA 02601 �� Thomas A. McKean Office 508-790-6265 w,; �l��.e � Dinetot of Public Health FAX 50��'��3344 ��������� ��" NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00,_9TATE SANITARY CUUE—IIJ_MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION The property owned by you located at was inspected on /f ?2VW3, Health Inspector for the Town of Barnstable, because of a complaint. The following violations of 105 CMR 410.00, State Sanitary Code II, Minimum Standards of Fitness for Human Habitation were observed: LA.-Sr You are directed to correct - ` violations within twenty - � 5 four (24) hours of receipt f this nvtic ,���-�� (� — �,.u ,w -�,'�.,ye c� e.a��'';r�.�,���� �Vie✓ You are also directed to correctri'',(e oe4e,) within -�✓� / J days/heoors- of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However, these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean Director of Public Health C ,v`7 �.� l�v may ;41 .�' � lj 3 �� "o,cv y _ 3. HAW HOess&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS FORM30 BOARD OF HEALTH CITY/TOWN W �Z� a DEPARTMENT ADDRESEr _ � TELEPHONE f q Address A d cupant Floor ;? Apartment No. No.of Occupants No.of Habitable Rooms— '9 No.Sleeping Rooms `7_ No. dwelling or rooming units����� ,,�� No.Stories, X Name and address of owner_Jg/_G_�/_1�/5 / s -f1l41 If Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EX Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,S t a i r w a : Obst'n.: Hall, Floor,Wall,Ceiling: Hall Li htin : ll Windows: / 'l HEATING rval t �sf/df'd�' //< Central ❑ Y ❑ N E air -D TYPE: Stacks, Flues,Vents: PLUMBING: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT J Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin, Shower or Tub: Infestation Rats, Mice, Roaches or Other. /Q ¢ Egress Dual and Obst'n: General Building Posted IV4# $a X Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY.- �f INSPECTOR A7- ITLE < � DATE �'� / G TIME ,�J P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. ,. ,.��..::n 'rni'�i'�".ii`t'C.':•.fy�"�'i4"��"P'i;�'�ry�7'y.�y.•�„�r'7M"'''�Ff'y}dx'+®+iai.-.fair,,..r�'y�FF�pti°Y,:'y{R!!'r"M;'��`1��T�y'4„�,"�j�{'4'R'�'�',y'�}���,r,': „'Kiti�+{� 'r7 �1'v°�ti �„ 'i ,:.a c:,� s ..� , •5 ^'Yr 'd � a y ,4 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shali be deemed conditions which may endanger or impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. SECTIONSENDER: COMPLETE THIS SECTION COMPLETE THIS ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Received by(Please Print Clearly) I B ,a elf Delivery II item 4 if Restricted Delivery is desired. OJ :,;. I ■ Print your name and address on the reverse C. Sig ire Lzc so that we can return the card to you. o■ Attach this card to the back of the mailpiece, Agent or on the front if space permits. X Addressee D. Is delivery address different from ite ; ? ❑Yes 1. Article Addressedto: n If YES,enter delivery address below: ❑ No 3. Service Type V/ > Nov 11111 Certified Mail ❑ Express Mail �(/ J ❑ Registered ❑Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number(C '-t�o*1:4 jice label) PS Form 881.1,July 1999 I ' i i I I t Domestic Return Receipt .)02595 00 M-0952 UNITED STATES POgg SEf3VJJCE F i r§t Cla s 1ldail +tj�: it t= +/Cli,} � �Pd gelFpes Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • Public Nitro IMM P.O.Box 534 I an* Massadwwft 02601 Y ,+9 ' e